802 Sparks Rd . j
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� �'o'-,�"�� ' ' Davie County Environmental Health � ' �0
� , • '' P.O.Box 848/210 Hospital Street /� I
� Mocksville,NC 27028 I(}I
(336)753-6780/Fax(336)753-1680
WELL PERMIT
�ccou�t #�: 990005474 . - T�X:P.1�€iEH#: 5853-54-5734-Well _ _ , . -
BiElc�i To: Elizabeth Fenwick . ; SuE�divisiart�.in�f�:,,������ _ � .
, Refer�r�ce Nar��e: , . ',.�,LocalioniAddress: 802 Sparks Road-27028;`
Proposed Fa�iiity: Residential Well ="<, . . :> : � �;".. P�o�er#y�Size',1,���'16 acres ; , ; •: - - - , : K .._,,� �:--�
�TC Numb�r: 0064 , . . ,-<� � _ .
Actions of the employees of the Davie County EH Section shall in no way be taken as a guarantee that this
well will produce water of any particular quantity or quality or for any amount of time. This permit is valid
for a period of 5 years from the date of issuance. This permit may be revoked if it is determined that there
has been a material change in any facticircumstances upon which this permit was issued.
Permit Type: New [� Repair ❑ Abandonment ❑
Proposed Well Lo tion Diagram Certificate of Completio,�Diagram
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Comments: � Driller: 1�IQ Q
. Certification#:
Grout Inspected: (� � Z�/� -
Well Head Inspected: � 2 Q
GPS Coordinates: a 2. � Q �.ZO�
EHS:, Date: (� EHS: Date:
W.P.7-08
Od 04 10 09:29a Ir�formation Seroices 3367531680 p.1
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APP� TION FOR P�2IVATE WELL PERMIT
'; _ 6 2010 vie County Environmental Heaith
��� P.O.Box 848/Z10 Hospltal Street
Mocksville,NC 27028
�`N�����j�EGG�I� LjH 336)753-6780!Fax(336)753-I680
• ***IMPORT.4NT'k'�*
THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF TF�REQUIRED II�TFORMAT[ON IS PROVIDED.
APPLICANT INFOItMATION
Name 1 ct.�j "- t.tJ(, � Contact Person 9'c9'zc��a
Address d S�f— r Home Phone �
City/State/ZiP 1 .� cS /b� Business Phone '
Name on Permit ifDif`'eren:than Above �
Mailing Address CitylState/Zip
PROPERTY INFORMATION _ *Date HouseJFaciIity Corncrs Flagged
NOTE: A survey lat o7 site�la�n.��'ust a mpazry this application. Included: ❑Site Plan �Plat(to scale)
` Owner's Name�����:�-�� �.a.r..c�c� Phone Number "I� {-j z�3
' Owner's Address City/State/Zip
Property Address �3 D 2, ,��, eQ� City 2 '
Lot Siae � � o�cic� Tax PTN# c�Z 1 j��-�'�jl.�-57J��
Subdivision Name(if applicable) S tion/Lo
Directions To Site:
DEVELOPMENT INFORMATION
Permit Type: New Well Well Repair Well tlbandonment Other(specify)
Facility Type: Residential � Food Service Church Commercial Other
Are There Any Septic Systems G�rrently On The Site? YES NO �
Do You Intend To Install A New Se tic System On This Site? YES � NO
TERMS AND CONDTTIONS:
This application must be accompanied by a plat or site plan of the property that includes the existing and proposed pmperty(ines
�vith dimensions,the specif c location of the facility and any existing or future appurtenances,the location of any existing septic
system,sewer lines,water lines,any existing water supplies and any surface waters. The agplicant is responsible for identif}+ing
nnd marking the property lincs and comers. 'Che applicant is zesponsible for making the site accessible.
By signi.ng this application,the applicant signifies that they understand the terms and conditions and that they give permission for
Davie County Environmental EIealth representatives to perform necessary field evaluafions and procedures deemed necessary to
determine the best locadon for a weil.
�� I� llv
Signe Date
Site Revisit Charge
Date(s):
ClientNotification Date:
EHS:
7/30/09 Account#�
�W///T ' f."_"_:__ L .
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� WA'�ER SAMPLE�SEWAGE SYSTEM CHECK RE�UEST Date Requested: 25� 71 I
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION Received By
-�
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WATER SAMPLE TYPE: �8acterial O Protected
C4� Chemical O Unprotected O Dug
� � 9, Other: O Bored O Drilled
�'Outside Spigot:y���/`t0145L O Other:
��..����.���.���.���.������.���.�.��.��������..����
SEWAGE SYSTEM CHECK: O Yes Vacant: O Yes O Approved
/ � O No O Disapproved
Owner's Name: �IL� .�i`1 r6N i � Buyer's Name
Property Address:
Directions: �l
0 O ! � �/"
Speciallnstructions: � S
Letter To: Closing Da e:
Attn: ----------- --------
� Date Taken: !
� Charges:
Telephone: � � By:
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DAV1E COUNTY ENVIRONMENTAL HEALTH Z 2
P.O.Box 848/210 Hospital Str�e,t — - ZZ
Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680 . ,
OPERATION PERMIT
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• �ccr�ur�t �: 990005474 Tax P1t�:EH#; 5853545734
Biflc�Ya: Elizabeth Fenwick Suf�divisiati Infc�:
RefereE�ce N�r��e:: Gary Boggs LocationiAddr�ss: Sparks Road-
Propc��ge! F�aci(ity: residence P�op�r�ty Size: 16 acres "
.
ATC Nut�ber: 5083
�
**NOTE**The issuance ofthis Operation Permit shall indicate the system described on the ATC has been installed
in compliance with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"
but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of
time.
System Type: 8 S.T.Manufacturer_�'4C,�"� Tank Date�� Tank Size /G�O
Pump Tank Size� � _
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System Installed By: �/(�`�./Y! {�/Q,� E.H.Specialis • Date:
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DCHD 11/06(Revised)
' i . DAVIE COUNTY ENVIRONMENTAL HEALTH
": "' ' P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680
_. AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION �
�cct�u�t #�: 990005474 "��x PI�€.�EH#: 5853545734 �
Billc� To: Elizabeth Fenwick Sub�ivi4ior� lnf�:
Re�ferwr�ce P�a��e: Gary Boggs l.ocatioNAddr�ss: Sparks Road-
f�rop�3s�;c9 F��:iEity: residence �cn�zr#y S�iz�: 16 acres �
t�TC N��'3b�3': 5083 Site Type: ❑N2w ❑Repair ❑Expansion
**NOTE**This Authorization to Gonstruct(ATC)MUST BE ISSUED by the Davie Courity Environmental
Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A
Wastewater Systems,Section.1900 Sewage Treatment arid Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VAL-ID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat
or the intended use change.
Residential Specifications: #Bedrooms2_#Bathrooms #People Basement❑ Basement plumbing0
Non-Residential Specifications: Facility Type � #People #Seats
Squaze Footage(or I�imensions of Facility)
Lot Size�_ Type of Water Supply: ❑County/City ❑Well ❑Community Well
System$pecifications: Design Wastewater Flow(GPD)�uv Tank Size b6UGAL.Pumn�,�,�G�AL.
Trench Width 3� Max.Trench Depth�� Rock Dept';�Z,,:,'�,Linear Ft.� �o d �
Site Modifications/Conditions/Other: � �� Z�%OI/�4(�u�
Contact the Davie County Environmental Health Section for final i�s' ::an of this system between
8:30-9:30a.m.on the da of installation. Tele hr_`.';-: ,�36 751-8760. "
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Environmental Health Specialist Date: ����
DCHD 11/06(Revised)
. • � Davie County Environmental Health
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax(336)753-1680
IMPROVEMENT PERMIT /
Account #: 990005474 Tax PIN/EH#: 5853545734
Billed To: Elizabeth Fenwick Subdivision Info:
Address: 2126 Forest Drive Location/Address: Sparks Road-
City: Winston-Salem Property Size: 16 acres
Reference Name: Gary Boggs
Proposed Facility: residence
**NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An
Authorization To Construct a wastewater system must be obtained from this office prior to the
construction/installation of a wastewater system or the issuance of a building permit(in compliance with
Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to
revocation if site plans,plat or the intended use change.
. Permit Type: �New ❑Repair �Expansion Permit Valid for: ,�5 Years ❑No Expiration
Residential Specifications: #Bedrooms�#Bathrooms #People Basement❑ Basement plumbing❑
Non-Residential Specifications:.Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD):��v Type of Water Supply: ❑County/City �.Well ❑Community Well
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Site Modifications/Permit Conditions: ,/�C'.1'1 � Q�. �l9�
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REh1NNING PROP�RT1(0�.. CORNER 1 1 (
\ ELIZABETH L. FE?`�'i�YIC l � , , �
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� ' Davie County Environmental Health
. . P.O.Box 848/210 Hospital Stre�t — ,
Mocksville,NC 27028 � �
(336)753-6780/Fax(336)753-1680
IMPROVEMENT PERMIT
� �,
Account #: 990005474 Tax PIN/EH#: 5853545734
Billed To: Elizabeth Fenwick Subdivision Info:
Address: 2126 Forest Drive Location/Address: Sparks Road-
City: Winston-Salem w
Property Size: 16 acres ��
Reference Name: Gary Boggs
Proposed Facility: residence
**NOTE**This Improvement Permit DOES NOT authorize the constructicjri of a wastewater system. An
Authorization To Construct a wastewater system must be obtained from this office prior to the
construction/installation of a wastewater system or the issuance of a building permit(in compliance with
Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to
, revocation if site plans,plat or the intended use change.
_.__._�_.__.____ �.____._ .____..____..._.�_�_.._.Y._..._.....------�.._....._.._.�_ ___..,_.__.__.._....__..___ ........_... __.._....... ..._..
Permit Type:. New ❑Repair OExpansion Permit Valid for: PI5 Years ONo Expiration
Residential Specifications: #Bedrooms 2 #Bathrooms #People Basement❑ Basement plumbing0
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility) �
Design Flow(GPD):�� Type of Water Supply: ❑County/City ❑Well �ommunity Well
Site Modifications/Permit Conditions:
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Environmental Health Specialist � Date 2
i.p.l 1-06
� , -
� R SITE EVALUATION/IMPROVEMENT PERMIT & ATC
� � Davie County Environmental Health
P.O.Box 848/210 Hospital Street
� O � '� �-��� Mocksville,NC 27028
PQR 1 � (336)753-6780/Fax(336)753-1680
EA
pplic tio • ��;� ion/Improvement Permit �Authorization To Construct(ATC) ❑ Bot
_ T e o Ap at�6 ew System ❑Repair to Existing System ❑Expansion/Modification of Existing y em or Facility
*� PORTANT***THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED: Refer to the INFORMATION BULLETIN for instructions. �
APPLICANT INFORMATION �
� �
Name 1 '�� l � �ontact Person Crc�t� `
Add'ress ��}-� Home Phone Q q 8 -- 1�„�6 �
City/State/ZIP �. B Business Phone 5 a�wt� `�o� 2� b
Name on PerrnitlATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facilit Corners Fla ed �
NOTE: A survey plat or site plan must accompany this application. Included: €�'S�ite Plan �Plat(to scale) �
(Permit is valid for 60 months with site plan,no expiration with complete plat.)
Owner's Name �l,��QD Phone Number
Owner's Address 1 c�, l� � � City/State/Zip� �����y� .. �)��'/�
Property Address`� .s S City
Lot Size /��-�,�..a� Tax PI # S'�S�S yS"� ��1
Subdivision Name(if applicable) Section/Lot#
Directions To Site:
If the answer to any of the following questions is"Yes",supporting documentation must be attached:
Are there any existing wastewater systems on the site?. _Yes �R10 � ,.
Does the site contain jurisdictional wetlands? . Yes vPd�
Are there any easements or right-of-ways on the site? Yes `iQo
Is the site subject to approval by another public agency? Yes v�o �
Will wastewater other than domestic sewage be generated? Yes�
IF RESIDENCE FILL OUT THE BOX BELOW��,� �u-�
#People ( #Bedrooms Z #Bathr�o ms � Garden Tub/Whirlpool ❑Yes o
Basement: OYes � Basement Plumbing: ❑Yes �3Qo
IF NON-RESIDENCE FILL OUT THE BOX BELOW �
Type of FacilityBusiness Total Square Footage of Building #People
#Sinks #Commodes #Showers #Urinals
Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: # Seats �
Type system requested: Conventional ❑Accepted ❑Innovative ❑Altemative �.Other
Water Supply Type: ❑ County/City Water 0 New Well C9'Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes �'1Qo
If yes,what type?
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand
that any permit(s)or ATC(s)issued hereafter are subject to suspension or revocation.if the site is altered,the intended use
changes,or if the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized
Renresentative of the Da��ie Coimty Health Department to conduct ne�:essary incpections to deterr::ine compliance�vitli applicable '
laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and
locating and flagging or staking the house/fa ility location,proposed well location and the location of any other amenities.
Site Revisit Charge
Prope owner's or owncr's legal representative signature
�, �_ ,_ �� � Date(s):
/.� J/ (� �Y�T�� ClientNotification Date:
Date �y�, J��� ��� (�.�..p EHS:
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f11A�(`T/lAI AAIn cllDcc�nc�n�,� cnn�i .0 � � ' � . �+�
_ • �. ' • . DAVIE COUNTY HEALTH DEPARTMENT
- ' Environmental Health Section
Soil/Site Evaluation �
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990005474 , Tax PIN/EH#: 5853545734 °�
Billed To: Elizabeth Fenwick Subdivision Infa
Reference Name: Gary Boggs � Location/Address: Sparks Road- ^5-/_ /
Proposed Facility: residence Propecty Size: 16 acres Date Evaluated: ��l GK.
� �/�ylz�co -�(�-Z
Water Supply: • On-Site Well ✓ Community Public
Evaluation By: Auger Boring V Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e position •
SlOpe % ' b 0 nv �'c �
HORIZON I DEPTH � O— p—�l ^ O
Texture rou . L ` � -
Consistence L (/�
Structure :r �� �
Mineralo
HORIZON II DEPTH � �� � _� L - O
Texture rou • � (, C
Consistence '
Structure
Mineralo -aCQ
HORIZON III DEPTH - -�( v
Texture rou CL., C L
Consistence ' %
Structure ' � A� ('
Mineralo � " '
HORIZON IV DEPTH
Texture rou
Consistence
Structure �
Mineralo ,
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION �
LONG-TERM ACCEPTANCE RATE . , .2, +
` r
SITE CLASSIFICATION: �J � 1 EVAL �Y: L 'C
LONG-TERM ACCEPTANCE RATE: •� OTHER(S)PRESENT: �
' ,� �c�
REMARKS: O�1 .(. �
LEGEND
I,�n�caoe Position
R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope
Texture .
S-Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt
SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
CON4I4T+.N . �
Msis�
VFR-Very friable FR-Friable FI-Firm VFT-Very firm EFI-Extremely fum
�
� NS-Non sticky SS-Slightly sticky S-Sticky _ VS -Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
s
Structure ,
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralogv
1:1,2:1,Mixed
Notes
Horizon depth-In inches
Depth of fill-In inches . .
Restrictive horizon-Thickness and inches from land surface . �
Saproli[e-S(suitable),U(unsuitable)
Soil wetness-Inches from land surface to free water or inches from land surface[o soil colors with chroma 2 or less „
Classification-S(suitable),PS(provisionally suitable),U(unsuitable)
LTAR-Long-term acceptance rate-gaUday/ft2 DCHi�05/()5(RevicPc�l
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